2010 January | Female Athlete Triad Coalition

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I am a team doctor for a cheer leading team. I wonder if my athletes may have the female athlete triad. How can I tell?

Identification of the athlete at risk for the female athlete triad allows for intervention to prevent the development of more serious health problems. In the pre-season, all elite athletes should have a pre-participation examination (PPE) to identify potential health risks and injuries. One section of the PPE is devoted to screening for the female athlete triad. This triad-specific PPE screening tool can be found on this website. Once you have identified the athlete at risk for the triad, you can investigate the athlete in more depth with tools such as a nutritional assessment, a hormonal profile and an evaluation of bone health. These guidelines can also be found in the PPE document on this website.

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I am a coach and many of my athletes are complaining of shin splints. Should I be concerned?

‘Shin splint’ is a term referring to tendonitis of the anterior lower leg muscles. This is often due to incorrect shoe wear or to training errors. If left untreated and ignored, the shin splint may lead to irritation of the bone resulting in a stress fracture in the lower leg bone (tibia).

In some athletes, a stress fracture can be a sign of poor nutrition and even an early indicator of underlying thinning of the bones known as osteopenia, or in more severe cases, osteoporosis. One thing that you can do to prevent shin splints and stress fractures is to ensure that your athletes have a balanced training program and that they have an evaluation of their foot wear to ensure appropriate biomechanics. In addition, it is important to ensure that your athletes have adequate nutritional intake of energy and calcium/Vitamin D.

Some female athletes develop thin bones as a result of the female athlete triad. Have your female athletes see a physician to assess the health of their menstrual cycles. The loss of regular menses is one of the signs of the triad, which may indicate that they are not getting adequate nutrition that will affect their hormonal function and subsequently the health of their bones. Often young female athletes restrict their nutritional intake which can have detrimental secondary effects on their health. Consulting a nutritionist is most helpful to assess the adequacy of energy & nutrient intake to ensure health & maximize sport performance.

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I am a parent of a 14y long distance runner. Is there something that I can do to ensure that my daughter will not get the Female Athlete Triad?

Thank you for asking this important question! Being proactive and focussing on prevention is preferable to waiting until health problems occur. Elite runners should have a nutritional assessment completed by a sports nutritionist to assess their energy balance (to ensure that their energy intake in the form of food is equal to their energy output – or energy expended during exercise.) Adequate energy intake and a healthy balanced diet is the key to preventing the female athlete triad. Elite runners should also have a yearly examination by a sports physician in the pre-season. The physician will look for signs to identify the athlete at risk for the female athlete triad. The physician may request blood work to assess hormonal status if your daughter has an abnormal menstrual cycle, and possibly a bone mineral density to determine bone health.

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Should I go on the Pill to combat the Triad?

Going on the Pill is not the best answer to fix Triad-related bone loss. Amenorrheic athletes are frequently prescribed hormonal contraceptives to prevent or slow bone loss, but this does not address the underlying problem — it only addresses the symptoms. The problem is energy, and energy should be part of fixing the problem. Contraceptives may normalize menstrual periods and provide estrogen, but they will not necessarily improve bone health. Athletes on birth control pills often believe they have addressed their Triad-related problems, and therefore are probably not being counseled to improve dietary habits. As a result, they may continue to travel down the energy deficiency path, which contributes to further bone loss. In fact, long-acting, progesterone-only contraceptives like Depo-Provera have been shown to cause bone loss, and the packaging for these drugs now includes a warning to this effect. Nevertheless, this particular drug remains popular among athletes who feel normal menstruation impairs their performance.

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Do I need to gain body weight in order to resume normal menstrual cycles?

Even small increases in body weight may be all that is necessary to resume menstrual cycles. Studies are ongoing to determine just how many calories are needed for normal menses to resume, but so far, it appears that even small increases in body weight (1-3 kg) may be all that is required to resume normal menstrual cycles by reversing the negative energy deficiency that caused the problem.

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Do I need to change my training to recover from the Triad?

An athlete does not need to reduce her training to avoid Triad or to resume normal menstrual cycles if she is amenorrheic (not menstruating). Many assume that the athlete must reduce exercise in order to avoid Triad, but the fact is that most athletes can effectively address Triad-related health problems with adequate nutrition. That said, if training can be reduced by adding one day of rest per week, resumption of normal menstruation will likely occur more quickly.

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Is it bad to not have normal menstrual cycles?

Losing your menstrual cycle is not healthy. Failing to menstruate for more than six months is unhealthy and should be evaluated by a physician. Athletes often view weight loss and losing their menstrual cycles as synonymous with improved athletic performance, and so they must be warned of the serious health risks of not menstruating — particularly, bone loss. Armed with the latest information and research, the athlete herself may be the first and best line of defense against this condition.